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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603279
Report Date: 09/10/2021
Date Signed: 09/10/2021 07:11:34 PM

Document Has Been Signed on 09/10/2021 07:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MINI MANOR HOMEFACILITY NUMBER:
198603279
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1606 S. HOLT AVETELEPHONE:
(424) 284-3258
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 6CENSUS: 4DATE:
09/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Naome LeibovTIME COMPLETED:
04:00 PM
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On 9/10/21 Licensing Program Analysts (LPA) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond conducted a case management. LPA and LPM was met by Naome Leibov, the house manager. LPA explained the purpose of today’s visit.

During today’s visit LPA and LPM observed Caregivers (CG) #1-2 and it was determine that CG #2 was not associated to the facility. CG #1 was not fingerprint cleared. LPA called the El Segundo office to confirm caregivers was not finger print cleared and associated to the facility,

During today’s visit LPA observed assistant administrator Eilat Nahum conducted a search in resident #1's bedroom without a reasonable basis. Administrator confiscated R1's baseball bat.

During today’s visit LPA observed residents #2's bedroom was having other resident's going in and out being used as a passageway in order to exit into the backyard.

During today’s visit LPA observed facility staff uses resident #2's room to store incontinent supplies in a cabinet

.Due time constraint LPA may issue additional deficiencies at a later date.

Deficiencies Cited Under California Code of Regulations Title 22, Division 6 Chapter 8 and civil penalties assessed.

Exit interview conducted report and appeal rights was given to Naome Leibov, the House Manager.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2021 07:11 PM - It Cannot Be Edited


Created By: Martessa Brown On 09/10/2021 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MINI MANOR HOME
FACILITY NUMBER: 198603279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited
CCR
87355(e)(1)(2)

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Criminal Record Clearance:
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17...(1) Obtain a California clearance or a criminal record exemption as required by the Department..
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement was not met as evidence by:
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Administrator will submit proof that Caregivers #1 Djie Nio finger print cleared and caregivers #2 Petrus Canssisus was not associated to the facility. All documents must be submitted to LPA by poc date 9/11/21.
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LPA and LPM observed Caregivers #1-2 both workiing in the facility. CG #1 Djie Nio did not have finger print clearance and CG #2 Petrus Canssisus was not associated. LPA and LPM called the El Segundo office and confirmed. LPA/LPM also confirmed.

This poses and immediate health and safety risk to all residence at the facility.
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Type B
09/16/2021
Section Cited
CCR87468.1(a)(1)

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Personal rights of residents in all facilities:
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidence by:
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Administrator to conduct a training in personal rights for all residents and submit training documents to LPA by poc dates including sign in sheets bu POC Date 9/16/21.
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LPA/LPM observed during visit Administrator conducting a search in residents #1 room with no reasonable basis and confiscated a bat.
This poses a potential health and safety risk to all residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2021 07:11 PM - It Cannot Be Edited


Created By: Martessa Brown On 09/10/2021 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MINI MANOR HOME
FACILITY NUMBER: 198603279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
87468.1(a)(2)

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Personal rights of residents in all facilities:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidence by:
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Administrator should room incontinent supplies from resident #2's bedroom to afford resident #2 privacy. Administrator will submit to LPA proof of by poc 9/16/21
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LPA/LPM observed incontinent supplies being stored in residents #2's bedroom in a cabinet.
This poses a potential health and safety risk to all residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


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